A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

A client requests an appointment to discuss their depression

A client who states that they are stopping their medication

A client who states they have been sleeping 12 hr a day

A client who is giving away their possessions

Answer and Explanation

The Correct Answer is D

A. Requesting an appointment to discuss depression is an indication that the client is seeking help, which is a positive step. It does not necessarily indicate an immediate risk of suicide.

B. Stating that they are stopping their medication raises concerns about treatment compliance, but it does not provide a clear indication of suicidal intent. It is important to assess the reasons for discontinuing medication and address any concerns.

C. Sleeping 12 hours a day can be a symptom of depression, but it does not necessarily indicate an immediate risk of suicide. It is crucial to assess the client's overall mental health and functioning.

D. A client who is giving away their possessions.
Giving away possessions can be a warning sign of suicidal intent. This behavior may indicate that the individual is preparing for the possibility of not needing those belongings in the future. It is crucial for the nurse to assess and intervene promptly if a client is exhibiting signs of suicidality.

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Correct Answer is ["A","B","D"]

Explanation

A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa.

B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa.

C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent.

D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention.

E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances.

F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first.

G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.

A. "I should sit on the side of the bed before standing up in the morning B. I may experience an increased libido." C. I will avoid drinking caffeinated beverages." D. I can no longer eat pepperoni pizza."

Correct Answer is A

Explanation

A. "I should sit on the side of the bed before standing up in the morning."
Amitriptyline is a tricyclic antidepressant that can cause orthostatic hypotension, a sudden drop in blood pressure upon standing. To minimize the risk of dizziness or fainting, clients taking amitriptyline should be advised to sit on the side of the bed for a few moments before standing up, especially in the morning when orthostatic changes may be more pronounced.

B. "I may experience an increased libido." This statement is not related to the common side effects of amitriptyline. Changes in libido are not typically associated with this medication.

C. "I will avoid drinking caffeinated beverages." While it's generally a good idea to limit caffeine intake, this statement is not a specific instruction related to amitriptyline. However, reducing caffeine consumption can be beneficial because amitriptyline may enhance the stimulant effects of caffeine.

D. "I can no longer eat pepperoni pizza." This statement is not directly related to amitriptyline. There are no specific dietary restrictions associated with amitriptyline use, and the client can continue to eat pepperoni pizza unless there are individual dietary concerns or interactions with other medications.

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A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D"]

Explanation

A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

A nurse is caring for a group of clients in a mental health facility. Which of the following clients recommend the physician or nurse practioner see first?

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

A nurse is preparing to administer haloperidol 5 mg IM to a client. Available is haloperidol 50 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)